Impact of exposure to patients with COVID-19 on residents and fellows: an international survey of 1420 trainees.

OBJECTIVES: To determine how self-reported level of exposure to patients with novel coronavirus 2019 (COVID-19) affected the perceived safety, training and well-being of residents and fellows. METHODS: We administered an anonymous, voluntary, web-based survey to a convenience sample of trainees worldwide. The survey was distributed by email and social media posts from April 20th to May 11th, 2020. Respondents were asked to estimate the number of patients with COVID-19 they cared for in March and April 2020 (0, 1-30, 31-60, >60). Survey questions addressed (1) safety and access to personal protective equipment (PPE), (2) training and professional development and (3) well-being and burnout. RESULTS: Surveys were completed by 1420 trainees (73% residents, 27% fellows), most commonly from the USA (n=670), China (n=150), Saudi Arabia (n=76) and Taiwan (n=75). Trainees who cared for a greater number of patients with COVID-19 were more likely to report limited access to PPE and COVID-19 testing and more likely to test positive for COVID-19. Compared with trainees who did not take care of patients with COVID-19 , those who took care of 1-30 patients (adjusted OR [AOR] 1.80, 95% CI 1.29 to 2.51), 31-60 patients (AOR 3.30, 95% CI 1.86 to 5.88) and >60 patients (AOR 4.03, 95% CI 2.12 to 7.63) were increasingly more likely to report burnout. Trainees were very concerned about the negative effects on training opportunities and professional development irrespective of the number of patients with COVID-19 they cared for. CONCLUSION: Exposure to patients with COVID-19 is significantly associated with higher burnout rates in physician trainees.

Rho and Rac, but not ROCK, are required for secretion of human and mouse eosinophil-associated RNases.

BACKGROUND: Eosinophil-associated RNases (EARs) are stored preformed in eosinophil cytoplasmic secretory granules and have a key role in eosinophil effector functions in host defence and inflammatory disorders. However, the secretion mechanisms of EARs are poorly understood. OBJECTIVE: Our study aimed to understand the involvement of cytoskeleton machinery in EAR secretion. METHODS: Fresh human and mouse eosinophils were stimulated with CCL11, and the secretion of enzymatically active EARs was detected using an RNase activity assay. The involvement of cytoskeletal elements or microtubules was probed using specific inhibitors. RESULTS: We found that dynamic polymerization of microtubules and cytoskeletal elements, such as Rho and Rac, is required for chemokine-mediated EAR secretion from human and mouse eosinophils. However, inhibition of ROCK (Rho-associated protein kinase) increased EAR secretion in human and mouse eosinophils even in the absence of chemokine stimulation, suggesting ROCK negatively regulates EAR secretion. CONCLUSIONS: Collectively, these data suggest a cytoskeleton-dependent mechanism of EAR secretion from eosinophils, findings that are pertinent to host defence, allergy and other eosinophil-associated diseases.

Now Tell Us What You Want: Information-Seeking Habits of Health Sciences Faculty.

Over the years, library collections have vastly changed due to an ever-growing presence of resources available online. Many libraries have experienced a dramatic decrease in the circulation of physical materials with the shift to online availability of materials. It is of great value to ensure libraries are meeting the needs of their users, and this can be accomplished by identifying their information-seeking patterns. The aim of this article is to examine how faculty use the library and to identify what services and resources are of value to their work.

Evaluation of a Nurse-Initiated Routine HIV Testing Pilot on a Medical-Surgical Unit.

National guidelines recommending a shift from risk-based to routine HIV testing for persons ages 13-64 are described. The role of nurses, particularly medical-surgical nurses, in increasing the number of people screened is discussed.

CCL11 elicits secretion of RNases from mouse eosinophils and their cell-free granules.

Rapid secretion of eosinophil-associated RNases (EARs), such as the human eosinophilic cationic protein (ECP), from intracellular granules is central to the role of eosinophils in allergic diseases and host immunity. Our knowledge regarding allergic inflammation has advanced based on mouse experimental models. However, unlike human eosinophils, capacities of mouse eosinophils to secrete granule proteins have been controversial. To study mechanisms of mouse eosinophil secretion and EAR release, we combined an RNase assay of mouse EARs with ultrastructural studies. In vitro, mouse eosinophils stimulated with the chemokine eotaxin-1 (CCL11) secreted enzymatically active EARs (EC(50) 5 nM) by piecemeal degranulation. In vivo, in a mouse model of allergic airway inflammation, increased airway eosinophil infiltration (24-fold) correlated with secretion of active RNases (3-fold). Moreover, we found that eosinophilic inflammation in mice can involve eosinophil cytolysis and release of cell-free granules. Cell-free mouse eosinophil granules expressed functional CCR3 receptors and secreted their granule proteins, including EAR and eosinophil peroxidase in response to CCL11. Collectively, these data demonstrate chemokine-dependent secretion of EARs from both intact mouse eosinophils and their cell-free granules, findings pertinent to understanding the pathogenesis of eosinophil-associated diseases, in which EARs are key factors.

Impact of missing data on analysis of postoperative cognitive decline (POCD).

BACKGROUND: There are a variety of techniques to handle missing data, such as removing observations with missing data from the analyses or estimating the missing values using various imputation algorithms. Dropping subjects from standard regression models and analyzing only completers, however, may bias results from the true value of reality. Likewise, 'last-observation-carried-forward' may not be an appropriate technique for studies measuring a particular variable over time. METHODS: This dataset was part of a larger prospective cohort study that examined postoperative cognitive decline (POCD) after surgery in older adults. Data collectors had provided the reasons for data being missing using adjectives including 'confused', 'incapable', 'stuporous', 'comatose', and 'intubated'. Data having these qualitative notations were re-coded as 'incapable' and trial scores of zero were recorded. This value of '0' indicated that the patient was cognitively incapable of performing the neuropsychological test. RESULTS: Missing data varied by cognitive test and postoperative day. Re-coding word list scores from missing to zero when a patient was too cognitively impaired to complete the tests improved sample size by 13.5% of postoperative day (POD) 1 and 12.8% on POD 2. Recoding missing data to zero for the digit symbol test resulted in 29.3% larger sample size on POD 1 and 22.7% on POD 2. Verbal fluency gained 15.7% sample size with re-coding for POD 1 and 13.7% for POD 2. Re-coding of each cognitive test reduced missing data sample size to 20-32% in all cognitive tests for each day. DISCUSSION: Our data suggest that using a scoring system that enters a value of '0' when patients are unable to perform cognitive testing did significantly increase the number of patients that met the diagnosis of postoperative cognitive decline using the criteria that were determined a priori and may lessen chances of type II error (failure to detect a difference).

Alternative activation.

A detailed study of the orphan receptor Nurr1, a regulator implicated in neurodegenerative diseases, reveals a new way for ligands to control their transcriptional activity.

Exploring Pembrolizumab-Induced Myocarditis, Myositis, and Myasthenia Gravis: A Comprehensive Literature Review and Case Presentation on Bladder Cancer.

Pembrolizumab, a humanized monoclonal anti-programmed cell death protein 1 (PD1) antibody, has shown efficacy in various malignancies. This article presents a case of stage III squamous cell carcinoma of the bladder treated with pembrolizumab, resulting in the development of a rare overlap syndrome known as myocarditis, myositis, and myasthenia gravis (IM3OS). While immune checkpoint inhibitors like pembrolizumab demonstrate notable antitumor activity, they also pose the risk of severe immune-related adverse events. The case underscores the importance of the early detection of IM3OS and the potential dangers associated with delayed diagnosis, offering valuable insights for healthcare providers managing patients on pembrolizumab therapy.

Impact of sex and gender on axSpA diagnosis and outcomes.

Axial spondyloarthritis (axSpA) was historically considered a disease of men, largely due to the recognition of a more severe, progressive phenotype, ankylosing spondylitis (AS; or radiographic axSpA, r-axSpA) aiding the clinical diagnosis [1,2]. Data demonstrating the near equal prevalence of axSpA in women only started to emerge in the last decades, highlighting intrinsic differences in disease phenotype, and clinical and imaging characteristics between sexes, which partly explain the issue of underdiagnosis in women. Similar to the evolving understanding of spondyloarthritis and the diseases that term describes, the concepts of gender and sex also warrant further clarification to accurately assess their potential role in disease pathophysiology and phenotypic expression. This narrative review delves into the most recent evidence from the literature on the true prevalence of sex differences in axSpA, and the impact of sex and gender on diagnosis, disease characteristics and treatment response in this, still underserved, chronic disease.

Evidence-Based Strategies to Enhance Weight Management Programs for Adult Military Beneficiaries: A Narrative Review.

INTRODUCTION: Overweight and obesity trends are on the rise among both civilian and military beneficiaries. The purpose of this narrative review was to evaluate nutrition, behavioral, lifestyle, pharmacotherapy, and alternative approaches to weight management (WM) among adults with a focus toward identifying gaps and evidence-based strategies that could support or enhance current and future WM programming among military adult beneficiaries. MATERIALS AND METHODS: A trained research team identified publications (January 2013-January 2020) for abstract review using key search terms and inclusion criteria. Two independent researchers conducted both the abstract review and full-paper bias scoring using selected Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. All eligible studies were assessed for bias and categorized based on key themes. The study was registered in PROSPERO, the international prospective register of systematic reviews. RESULTS: The research team identified 741 articles, with 278 meeting final inclusion criteria. The mean bias score was 7.5 ± 3.9 (score of 0-13; higher indicating fewer bias factors), with 64% scoring ≥9. Factors contributing to low bias included intervention compliance, dropout rate, and inability to blind participants. The most common published weight-loss interventions included a combination of therapies (59%), diet/supplement (17%), other approaches (12%), behavior change (7%), and exercise (6%). Themes identified to improve WM outcomes included leveraging technology, increasing intervention interactions, community support, emphasis on early weight loss, pharmacotherapy risk-benefit, enhanced behavioral component, resistance exercise, mindfulness, and benefits of quality-of-life measures. CONCLUSIONS: Reviewers identified several validated tools and techniques to augment and update existing WM programming to improve health and weight outcomes. The review affirmed use of individualized dietary patterns and not a "one-size-fits-all approach" as well as incorporating more comprehensive and team-approached treatments to make the best use of tools and strategies to enhance outcomes.

Nursing the Nuu-chah-nulth Way: Communities Driving Nursing Policy Priorities.

Rural and remote Indigenous communities face unique challenges, and they must drive solutions for sustaining and maintaining distinct nursing practices. Resourcing Indigenous community needs and aspirations for health depends on sustainable funding and an appropriately resourced nursing workforce. An Indigenous community-engaged research team led a program of study exploring Indigenous systems of care with three distinct communities. We used Indigenous research methodologies to identify obstacles to care and ways to advance nursing and healthcare delivery according to unique values and demographical and geographical influences. Using a collaborative analysis approach with communities, we identified themes related to resourcing nursing positions, supporting nursing education and valuing nursing influence in determining program priorities. The voice of the community in research is a powerful force for advocacy, ensuring that nurses are supported in relationships with communities and in designing programs that fit the community's vision for health and wellness. We recognize the essential contributions of nurse leaders to policy processes in formulating and coordinating ideas for program redesign across and within levels of organizations for health and social justice impacts. We conclude our paper by noting implications for nursing leadership in diverse settings with the goal of sustaining a nursing workforce to provide culturally safe, wellness-focused care.

Librarian integration in a four-year medical school curriculum: a timeline.

The Taubman Health Sciences Library (THL) is integrated in all four years of the University of Michigan Medical School (UMMS) curriculum. Information resources are introduced at strategic points throughout the curriculum so that students receive training at times when they are most likely to need the resource. Most of the core instruction sessions are taught in teams that consist of librarians and UMMS faculty, which provides unique learning opportunities for students. This article describes each THL instruction activity in the four-year undergraduate UMMS curriculum and provides commentary on the overall effectiveness of this integrated approach to instruction.

Pregnancy and Management in Women with Rheumatoid Arthritis, Systemic Lupus Erythematosus, and Obstetric Antiphospholipid Syndrome.

Management of women with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and obstetric antiphospholipid syndrome (APS) during pregnancy presents unique clinical challenges. Women with both RA and SLE can have disease flares during pregnancy, leading to pregnancy complications, such as preeclampsia, small-for-gestational-age infants, and preterm delivery. Disease should be under control prior to conception. Women with obstetric APS need to be anticoagulated during pregnancy. Many but not all antirheumatic medications can be used during pregnancy and lactation.

Social Media for Research Discourse, Dissemination, and Collaboration in Rheumatology.

Social media has become an important venue for rheumatologists, patients, organizations, and other stakeholders to discuss recent research advances in diagnosis and management of rheumatic disorders. In this article, we describe the current state of how social media may enhance dissemination, discourse, and collaboration in rheumatology research. Social media may refer to social platforms like Twitter and Instagram or digital media like podcasts and other websites that are operated for providing as free, open-access medical education (FOAM). Twitter has been one of the most active social media venues and continues to host a vibrant rheumatology community. Examples of research discussions on Twitter include organic user tweets, educational threads ("tweetorials"), live-tweeting academic conferences, and journals posting recently-accepted articles. Some research collaborations have been initiated through social media interactions. Social media may also directly contribute to research by facilitating the recruitment of study participants and the collection of survey-based data. Thus, social media is an evolving and important tool to enhance research discourse, dissemination, and collaboration in rheumatology.

The impact of COVID-19 on rheumatology training-results from the COVID-19 Global Rheumatology Alliance trainee survey.

Objective: The aim was to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on the clinical experiences, research opportunities and well-being of rheumatology trainees. Methods: A voluntary, anonymous, Web-based survey was administered in English, Spanish or French from 19 August 2020 to 5 October 2020. Adult and paediatric rheumatology trainees were invited to participate via social media and email. Using multiple-choice questions and Likert scales, the perceptions of trainees regarding the impact of the COVID-19 pandemic on patient care and redeployment, learning and supervision, research and well-being were assessed. Results: There were 302 respondents from 33 countries, with 83% in adult rheumatology training. An increase in non-rheumatology clinical work was reported by 45%, with 68% of these having been redeployed to COVID-19. Overall, trainees reported a negative impact on their learning opportunities during rheumatology training, including outpatient clinics (79%), inpatient consultations (59%), didactic teaching (55%), procedures (53%), teaching opportunities (52%) and ultrasonography (36%). Impacts on research experiences were reported by 46% of respondents, with 39% of these reporting that COVID-19 negatively affected their ability to continue their pre-pandemic research. Burnout and increases in stress were reported by 50% and 68%, respectively. Physical health was negatively impacted by training programme changes in 25% of respondents. Conclusion: The COVID-19 pandemic has had a substantial impact on rheumatology training and trainee well-being. Our study highlights the extent of this impact on research opportunities and clinical care, which are highly relevant to future curriculum planning and the clinical learning environment.

Rapid Adoption of Telemedicine in Rheumatology Care During the COVID-19 Pandemic Highlights Training and Supervision Concerns Among Rheumatology Trainees.

OBJECTIVE: To evaluate the impact of telemedicine use during the coronavirus disease 2019 (COVID-19) pandemic on rheumatology trainees. METHODS: A voluntary, anonymous, web-based survey was administered in English, Spanish, or French from August 19 to October 5, 2020. Adult and pediatric rheumatology trainees were invited to participate via social media and email. Using multiple-choice questions and Likert scales, the survey assessed prior and current telemedicine use, impact on training, and supervision after COVID-19 prompted rapid telemedicine implementation. RESULTS: Surveys were received from 302 trainees from 33 countries, with 83% in adult rheumatology training programs. Reported telemedicine use increased from 13% before the pandemic to 82% during the pandemic. United States trainees predominantly used video visits, whereas outside the United States telemedicine was predominantly audio only. Most (65%) evaluated new patients using telemedicine. More respondents were comfortable using telemedicine for follow-up patients (69%) than for new patients (25%). Only 39% of respondents reported receiving telemedicine-focused training, including instruction on software, clinical skills, and billing, whereas more than half of United States trainees (59%) had training. Postconsultation verbal discussion was the most frequent form of supervision; 24% reported no supervision. Trainees found that telemedicine negatively impacted supervision (50%) and the quality of clinical teaching received (70%), with only 9% reporting a positive impact. CONCLUSIONS: Despite widespread uptake of telemedicine, a low proportion of trainees received telemedicine training, and many lacked comfort in evaluating patients, particularly new patients. Inadequate supervision and clinical teaching were areas of concern. If telemedicine remains in widespread use, ensuring appropriate trainee supervision and teaching should be prioritized.

Characteristics and Outcomes of People With Gout Hospitalized Due to COVID-19: Data From the COVID-19 Global Rheumatology Alliance Physician-Reported Registry.

OBJECTIVE: To describe people with gout who were diagnosed with coronavirus disease 2019 (COVID-19) and hospitalized and to characterize their outcomes. METHODS: Data on patients with gout hospitalized for COVID-19 between March 12, 2020, and October 25, 2021, were extracted from the COVID-19 Global Rheumatology Alliance registry. Descriptive statistics were used to describe the demographics, comorbidities, medication exposures, and COVID-19 outcomes including oxygenation or ventilation support and death. RESULTS: One hundred sixty-three patients with gout who developed COVID-19 and were hospitalized were included. The mean age was 63 years, and 85% were male. The majority of the group lived in the Western Pacific Region (35%) and North America (18%). Nearly half (46%) had two or more comorbidities, with hypertension (56%), cardiovascular disease (28%), diabetes mellitus (26%), chronic kidney disease (25%), and obesity (23%) being the most common. Glucocorticoids and colchicine were used pre-COVID-19 in 11% and 12% of the cohort, respectively. Over two thirds (68%) of the cohort required supplemental oxygen or ventilatory support during hospitalization. COVID-19-related death was reported in 16% of the overall cohort, with 73% of deaths documented in people with two or more comorbidities. CONCLUSION: This cohort of people with gout and COVID-19 who were hospitalized had high frequencies of ventilatory support and death. This suggests that patients with gout who were hospitalized for COVID-19 may be at risk of poor outcomes, perhaps related to known risk factors for poor outcomes, such as age and presence of comorbidity.

SARS-CoV-2 Infection and COVID-19 Outcomes in Rheumatic Diseases: A Systematic Literature Review and Meta-Analysis.

OBJECTIVE: The relative risk of SARS-CoV-2 infection and COVID-19 disease severity among people with rheumatic and musculoskeletal diseases (RMDs) compared to those without RMDs is unclear. This study was undertaken to quantify the risk of SARS-CoV-2 infection in those with RMDs and describe clinical outcomes of COVID-19 in these patients. METHODS: We conducted a systematic literature review using 14 databases from January 1, 2019 to February 13, 2021. We included observational studies and experimental trials in RMD patients that described comparative rates of SARS-CoV-2 infection, hospitalization, oxygen supplementation/intensive care unit (ICU) admission/mechanical ventilation, or death attributed to COVID-19. Methodologic quality was evaluated using the Joanna Briggs Institute critical appraisal tools or the Newcastle-Ottawa scale. Risk ratios (RRs) and odds ratios (ORs) with 95% confidence intervals (95% CIs) were calculated, as applicable for each outcome, using the Mantel-Haenszel formula with random effects models. RESULTS: Of the 5,799 abstracts screened, 100 studies met the criteria for inclusion in the systematic review, and 54 of 100 had a low risk of bias. Among the studies included in the meta-analyses, we identified an increased prevalence of SARS-CoV-2 infection in patients with an RMD (RR 1.53 [95% CI 1.16-2.01]) compared to the general population. The odds of hospitalization, ICU admission, and mechanical ventilation were similar in patients with and those without an RMD, whereas the mortality rate was increased in patients with RMDs (OR 1.74 [95% CI 1.08-2.80]). In a smaller number of studies, the adjusted risk of outcomes related to COVID-19 was assessed, and the results varied; some studies demonstrated an increased risk while other studies showed no difference in risk in patients with an RMD compared to those without an RMD. CONCLUSION: Patients with RMDs have higher rates of SARS-CoV-2 infection and an increased mortality rate.

Pregnancy and Management in Women with Rheumatoid Arthritis, Systemic Lupus Erythematosus, and Obstetric Antiphospholipid Syndrome.

Management of women with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and obstetric antiphospholipid syndrome (APS) during pregnancy presents unique clinical challenges. Women with both RA and SLE can have disease flares during pregnancy, leading to pregnancy complications, such as preeclampsia, small-for-gestational-age infants, and preterm delivery. Disease should be under control prior to conception. Women with obstetric APS need to be anticoagulated during pregnancy. Many but not all antirheumatic medications can be used during pregnancy and lactation.